Eye on Ethics

Navigating the New Age of Electronic Counseling
By Frederic G. Reamer, PhD
Social Work Today
July/August 2006

Yvonne recently left her job as a therapist at a family service agency to develop her own independent counseling practice.

For several years, Yvonne has been interested in the use of Internet technology to provide counseling services. Yvonne decided to build her new practice by offering both in-person and Internet-based counseling. Yvonne believes her distance counseling services may appeal to people who live a considerable distance from a counselor or are reluctant to meet with a counselor in person.

The pioneers of social casework—such as Harriett Bartlett, Florence Hollis, Helen Harris Perlman, and Mary Richmond—could not have imagined contemporary social workers’ use of Internet and other electronic technology to deliver clinical services. Computers did not exist when these women formulated the profession’s earliest theories and methods of social casework. For them, clinical services typically meant in-person conversations with clients in agency settings.

Clearly, the clinical world has changed. Nearly a century after social work’s formal inauguration, some social workers have begun offering clinical services via the Internet and other electronic media. Today, social workers use electronic technology to provide the following types of services:

• E-therapy: Social workers provide ongoing one-on-one counseling services to clients using e-mail, real-time chat, Web-based messaging, and voice-over IP (Internet phone). People who type “Internet therapy” in a computer search engine will be inundated with e-therapy (or cyber-therapy) options. Clinicians typically charge clients by the hour (online chat) and by the message (Web mail exchange).

• Discussion groups and chat rooms: Social workers facilitate and monitor electronic discussion among group members who share some concern—for example, eating disorders, addictions, parenting, or trauma.

• Mental health advice: Social workers respond to individual questions in depth. For example, social workers may provide detailed responses to questions about coping with trauma, options for the treatment of alcoholism, or ways to locate residential treatment services for struggling teens.

• Videoconferencing: Social workers “meet” with clients electronically by using videoconferencing studios in their respective locations. Participants see each other on screens and engage in real-time dialogue broadcast on speakers.

Protect Yourself and Your Clients
To many observers, electronic mental health services are a mixed blessing. Many social workers acknowledge potential benefits when electronic services make it possible for clients to access services at times convenient for them and from remote locations where mental health professionals may not be accessible; serve clients who are uneasy about meeting with a clinician in person and clients who have a disability and have difficulty traveling to a practitioner’s office; protect the privacy of people who are prominent or live in small communities; and enhance access to services to clients with busy travel schedules. Electronic mental health services also work well for social workers who want more flexible schedules, to work from home, and to expand their client pool beyond their immediate geographical area.

But there are also serious potential downsides and limitations to online and electronic mental health services. Social workers who provide services electronically may have difficulty assisting clients in a crisis; interpreting clients’ subtle body language and other nonverbal cues (unless using high-quality videoconferencing); verifying a client’s true identity; conducting a comprehensive biopsychosocial assessment; and protecting client confidentiality.

The NASW Code of Ethics does not prohibit online and other forms of electronic counseling. However, the code does highlight a series of ethical considerations related to confidentiality, informed consent, professional competence, and client records (see standards 1.03[e], 1.04[b,c], 1.07[l,m], 4.01[b]). To practice ethically, social workers should:

• ask potential clients to complete a comprehensive assessment form that asks for information comparable to what would be obtained in a competent biopsychosocial assessment;

• review the potential benefits and risks of online and electronic counseling (Be sure that clients understand that online and electronic counseling is an unproven medium and that results cannot be guaranteed.);

• discuss pertinent confidentiality issues, such as access family members and employers may have to one’s e-mail account that is used for online counseling. (Describe the security precautions—for example, encryption steps—you have taken to protect client confidentiality to the greatest extent possible.);

• provide clients with communication tips and guidelines to enhance the quality of the electronic exchange to ensure that clients share all clinically relevant information;

• establish explicit plans to ensure that clients have access to competent services in the event of a crisis or emergency—for example, identifying local emergency service options and local contacts;

• offer to help clients locate local services and resources that may be helpful;

• provide clear instructions for follow-up care when services are terminated;

• offer clients an opportunity to provide feedback about the quality of the electronic services they have received (Establish a mechanism to respond to clients’ concerns and complaints.);

• consult relevant code of ethics standards and licensing statutes;

• disclose any sponsorships, affiliations, or financial incentives that could affect a client’s perception of your independence or judgment;

• clearly disclose all relevant fees for services provided;

• summarize your qualifications and expertise; and

• consult with an attorney who specializes in professional malpractice to ensure compliance with prevailing ethical and legal standards. Review all pertinent liability risks, especially related to the legal implications of providing online services to clients who live in another state or country.

Standards for the provision of online and electronic services are evolving. Social workers are still in the early stages of their efforts to wrestle with a daunting array of ethical issues triggered by the use of computers and other electronic technology that did not exist during most of the profession’s history. The vast majority of practicing social workers cultivated their ethical instincts during an era when ethical issues were confined to in-person meetings with clients. In contrast, today’s social work students are entering a profession filled with unprecedented ethical challenges involving the use of electronic technology that did not exist when most contemporary social workers completed their formal education. Social workers should be vigilant in their efforts to identify and address the novel ethical issues that are emerging with the advent of computer and other electronic technology.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.